Varón de edad avanzada con soplo sistólico. Propuesta de un esquema de diagnóstico diferencial / Elderly male with systolic murmur. A proposal of a differential diagnosis schema

La presencia de un soplo sistólico a la auscultación cardiaca es un hallazgo frecuente en los pacientes de edad avanzada. El origen de estos soplos, puede ser debido a causas banales sin trascendencia clínica ni pronóstica o pueden ser provocados por patologías graves que requieren tratamiento específico. La prueba de elección para el estudio de un soplo es, en la actualidad, la ecocardiografía döppler. Sin embargo, la auscultación minuciosa junto con la realización de determinadas maniobras auscultatorias y el estudio del pulso carotideo son técnicas fundamentales en la consulta del médico de familia que nos permiten aproximarnos al diagnóstico y seleccionar a los pacientes para la realización de un estudio ecocardiográfico (AU)

The presence of a systolic murmur on cardiac auscultation is a frequent finding in the elderly patient. The origin of these murmurs may be due to insignificant causes without clinical or prognostic importance or may be caused by serious conditions that require specific treatment. The test of choice to study a murmur is currently the Doppler echocardiography. However, careful auscultation together with the performance of some auscultation maneuvers and the study of the carotid pulse are fundamental techniques in the family medical consultation that allow us to approach the diagnosis and select the patient who need an echocardiography study AU)

Samuel A. Levine and the history of grading systolic murmurs.

Murmurs were described first by Laennec in 1819, after which the significance of a murmur became a matter of debate. By the late 19th century, many physicians regarded systolic murmurs as "organic," whereas others believed that they were often "functional." Samuel Levine became a central figure in separating functional from organic systolic murmurs. Freeman and Levine's 1933 study of 1,000 "noncardiac" subjects determined the frequency, cause, and significance of systolic murmurs. Murmurs were rated on a scale of 1 to 6 grades of intensity. Approximately 20% of their patients had grade 1 or 2 systolic murmurs. Hypertension, fever, tachycardia, and anemia were common factors, and the murmurs were considered functional because they would often disappear when these causes were controlled. Of 19 subjects with grade 3 or 4 murmurs, all were determined to have organic heart disease or anemia. Thus, louder systolic murmurs were found to be a significant finding, as were the cause, location, and effects of posture. They concluded that systolic murmurs often have an explanation and that their grade can be useful in the diagnosis and prognosis. They cautioned that a loud systolic murmur did not necessarily indicate a bad prognosis or even serious heart disease. Levine's system of grading a systolic murmur is valuable and persists into the 21st century.